ADVANCES IN MATERIALS AND CONCEPTS IN
FXED PROSTHODONTICS: A SELECTION OF POSSIBLE
TREATMENT MODALITIES
PRESENTED BY – DR. SHIVANGI BHATNAGAR
INTRODUCTION
• Treatment options in fxed prosthodontics have changed signifcantly in recent decades.
• Three main developments have strongly infuenced these changes.
• First, minimally invasive treatments have increasingly become feasible in restorative dentistry, thanks to
the introduction of the adhesive technique in combination with restorative materials with translucent
properties comparable to those of natural teeth.
• Mechanical anchorage of restorations via conventional cementation, a predominantly subtractive method, is
gradually being superseded by a primarily defect-orientated additive approach.
• Second, modifications of conventional treatment procedures have led to the development of an economical
approach to the removal of healthy tooth structure, as the planned outcome is defned in a wax-up before the
treatment itself is commenced.
• This wax-up is then used for reference during tooth preparation.
• Third, digital technology delivers important additional information including 3d data, for analysis,
diagnostics, communication, restorative designs and treatment planning, improving reproducibility. Also,
the computer-aided design/manufacturing (CAD/CAM) process facilitates more standardised fabrication
processes and quality improvements in materials, and provides access to new materials ofering favourable
options during the pre-treatment period as well as for subsequent defnitive restorations.
BACKGROUND
• At present, conventional treatment with metal based crowns and fixed dental prostheses (fdps) are
considered the gold standard for clinical success and survival.
• However, the extensive removal of tooth structure associated with full coverage crowns and fdps on
prepared abutment teeth remains a major drawback.
• A retrospective clinical study has demonstrated that the 15-year survival probability of vital pulps was
81.2% in metal-ceramic single crowns and only 66.2% in FDP abutments.
• Foster found an endodontic complication rate of 21% for fdp abutments after six years.
• An initial quantification of hard tissue removal with diferent preparation confgurations revealed that up to
72% of the clinical crown will be removed in full crown preparations in the anterior and posterior regions.
• Several in vitro studies on endodontically treated teeth have found that preserving greater amounts of
natural tooth structure has a signifcant positive efect on fracture resistance in all tooth types.
• Up to 45% more tooth structure can be preserved by opting for partial rather than complete coverage when
restoring endodontically-treated molars
• Against this background, fxed prosthodontics has been undergoing a paradigm shif towards less invasive
methods in recent years. Prosthetic concepts have also become increasingly well-differentiated in recent
decades
INNOVATIVE PRE-TREATMENT WITH
CAD/CAM POLYMERS
• Pre-treatment with occlusal splints is an important step in a structured concept for complex prosthetic
rehabilitations and serves to determine and stabilise a physiological condylar position.
• However, the willingness of patients to wear conventional splints during daytime is limited, mostly due to
aesthetic and phonetic restrictions, limiting their efficiency. With the introduction of CAD/cammilled
polymers, novel alternatives to splints have become available.
• Designed according to a diagnostic wax-up and milled and fnished to full contour from tooth-coloured
polycarbonate, these splints approximate the defnitive restoration in terms of function and aesthetics
CONVERSION TO DEFNITIVE ALL-CERAMIC
RESTORATIONS
• All-ceramic anterior veneers
• Encouraged by positive long-term clinical results, there has been a steady expansion of the range of
indications for all-ceramic veneers.
• Today, veneers are also used to restore the biomechanics of the dentition, establish adequate function, mask
highly discoloured endodontically-treated teeth, and for other purposesveneer preparations are subject to
stringent principles, but they still ofer a high degree of fexibility in terms of the restorative design,
depending on the clinical situation (tooth position, degree of destruction, occlusal conditions, periodontal
surroundings etc).
• This is true for both the incisal design and for its interproximal extension.
• The long wrap design is therefore advantageous in severe discolouration, diastemas, extensive shape
modifcations, slide midline corrections, black triangles and large fllings.
• Furthermore, the long wrap design is recommended for veneers in the immediate vicinity of crowns, as it
allows the contact area between the two restorations to be executed in ceramics.
• Circular preparation designs (360° veneers), also known as ‘full wrap’ veneer designs, are particularly
recommended for complex cases that require increasing the vertical dimension of occlusion to close the
resultant free space on the palatal aspect of the maxillary anterior teeth.
• All-ceramic occlusal onlays
• Adhesively connected all-ceramic occlusal onlays are a reliable treatment option for the posterior region.
• Glass ceramic onlays appear to be ideally suited for rebuilding abraded and eroded posterior teeth because
they ofer enamellike properties and a favourable interface behaviour glass ceramic onlays appear to be
ideally suited for rebuilding abraded and eroded posterior teeth because they ofer enamel like properties and
a favourable interface behaviour
• It is essential for the preparation margins to be located predominantly in enamel. Extensive silicate ceramic
onlays have displayed a favourable stress response pattern and with almost exclusively compressive forces
at the interface in in vitro studies. It is generally useful to distinguish between pure onlays, involving only
occlusal surfaces, and onlay veneers, involving the vestibular surface. The latter are indicated if a major
shade modifcation in the aesthetic region (premolar) is required .
• Resin-bonded anterior all-ceramic fdps
• Today, most crbfdps are made with frameworks made of materials with a high modulus of elasticity, such as
base-metal alloys or zirconia ceramics .
• They are used in the anterior region as an alternative to implant-supported restorations for single teeth if
implant treatment is contraindicated, extensive surgical interventions should be avoided, the space available
is insufcient for implant treatment, the patient is too young or too old, or if an implant is simply not wanted.
• CONVENTIONAL FDPS MADE OF ZIRCONIA LITHIUM DISILICATE CERAMICS
WAS INTRODUCED IN 1998 AS A RELIABLE METAL-FREE MATERIAL FOR
DIFERENT TYPES OF SINGLE-TOOTH RESTORATIONS. FOR SINGLE CROWNS,
LONG-TERM CLINICAL SURVIVAL RATES COMPARABLE TO METAL CERAMIC
CROWNS HAVE BEEN REPORTEDLITHIUM DISILICATE CERAMICS WAS
INTRODUCED IN 1998 AS A RELIABLE METAL-FREE MATERIAL FOR DIFERENT
TYPES OF SINGLE-TOOTH RESTORATIONS. FOR SINGLE CROWNS, LONG-TERM
CLINICAL SURVIVAL RATES COMPARABLE TO METAL CERAMIC CROWNS HAVE
BEEN REPORTED
DISCUSSION
• WITH THE INTRODUCTION OF DIGITAL TECHNOLOGIES AND ACCESS TO NEW RESTORATIVE MATERIALS,
CLINICIANS ARE FACING A CONTINUOUSLY INCREASING RANGE OF TREATMENT OPTIONS IN FXED
PROSTHODONTICS. TESE OPTIONS ALLOW STRATEGIES AND MATERIALS TO BE SELECTED SPECIFCALLY FOR
THE INDIVIDUAL PATIENT’S NEEDS.A PARADIGM SHIFT TOWARDS LESS INVASIVE TREATMENT OPTIONS IS
OBVIOUS; THE OVERALL AIM IS TO REACH THE TREATMENT GOAL WHILE REMOVING THE LEAST POSSIBLE
AMOUNT OF NATURAL TISSUE.
• TE CLINICAL RESULTS WITH DIRECT COMPOSITES AS A DEFINITIVE RESTORATIVE MATERIAL WERE INITIALLY
GOOD, ESPECIALLY IN THE ANTERIOR REGION.96,97 HOWEVER, CLINICAL FOLLOW-UPS SHOWED THAT IN
MORE COMPLEX CASES, DIRECT POSTERIOR COMPOSITE RESTORATIONS DISCERNIBLY DETERIORATED AFER
FVE AND A HALF YEARS AND MORE, IN TERMS OF SURFACE TEXTURE, ANATOMICAL SHAPE AND MARGINAL
FT.98 TE SURVIVAL RATES OF COMPOSITE RESIN AS A RESTORATIVE MATERIAL IN COMPLEX DIRECT
REHABILITATIONS DEPEND ON THE TOOTH POSITION, BEING MOST UNFAVOURABLE IN THE CASE OF MOLARS.
• DESPITE THE NUMEROUS IN VITRO STUDIES ON CAD/CAM COMPOSITE RESINS AND
POLYMER-INFILTRATED CERAMICS, CONTROLLED, RANDOMISED CLINICAL TRIALS
STILL REMAIN THE GOLD STANDARD AGAINST WHICH TO COMPARE THE CLINICAL
PERFORMANCE OF NEW MATERIALS. AS A CONSEQUENCE, THE AUTHORS STILL
CONSIDER ALL_X0002_CERAMIC RESTORATIONS THE TREATMENT OF CHOICE FOR
DEFNITIVE RESTORATIONS, ESPECIALLY IN COMPLEX REHABILITATIONS WHERE THE
MASTICATORY FORCES ARE BORNE SOLELY BY THE RESTORATIONS. HOWEVER, THE
PREPARATIONS SHOULD BE AS MINIMALLY INVASIVE AS POSSIBLE AND DEVELOPED
INDIVIDUALLY IN ACCORDANCE WITH THE CHOSEN MATERIAL AND TYPE OF
RESTORATION.
CONCLUSION
• DENTISTS PROVIDING FXED PROSTHETIC RESTORATIONS HAVE A VAST ARRAY OF
TREATMENT ALTERNATIVES TO CONVENTIONAL AND, ESSENTIALLY, MORE INVASIVE
PROCEDURES. THE INTRODUCTION OF DIGITAL TECHNOLOGIES HAS PAVED THE WAY FOR
INNOVATIVE TREATMENT STRATEGIES AND RESTORATIVE CONCEPTS IN TERMS OF NEW
DIAGNOSTIC TOOLS, BENEFTS IN COMMUNICATION AND TREATMENT PLANNING, AND
ACCESS TO NEW MATERIALS WITH EXTENDED INDICATIONS. TE INTRODUCTION OF NEW
POLYMER MATERIALS SUPPORTS INNOVATIVE REVERSIBLE PRE-TREATMENT CONCEPTS,
SUCH AS: CAD/CAM TOOTH-COLOURED FULLY-CONTOURED REMOVABLE SPLINTS; AND
NEW CAD/CAM CERAMICS WHICH PROVIDE NEW INDICATIONS FOR DEFNITIVE
RESTORATIONS. MANY METAL-FREE TREATMENT MODALITIES INTRODUCED IN THE LAST
DECADES.
• ARE NOW BACKED UP BY VALID LONG-TERM DATA. REGARDING THE MATERIAL CLASS OF
CERAMICS, THE RELEVANT TREATMENT OPTIONS ARE CONSIDERED TO BE SCIENTIFCALLY
VALIDATED FOR NUMEROUS INDICATIONS. ON THE OTHER HAND, SUFFICIENT LONG-TERM
RESULTS ON THE USE OF CAD/CAM COMPOSITE RESINS AND POLYMER-INFILTRATED
CERAMICS FOR DEFINITIVE RESTORATIONS AND NOVEL CLASSES OF ZIRCONIA ARE NOT
AVAILABLE YET. GENERALLY, THE METHODS DESCRIBED IN THIS ARTICLE ARE
TECHNIQUE-SENSITIVE AND THEREFORE REQUIRE THE CLINICIAN AND TECHNICIAN TO
HAVE WELL_X0002_DEVELOPED SKILLS AND EXPERIENCE. AND WITH ALL THAT, THE
PRESENT REPORT HAS ONLY BEEN ABLE TO TOUCH UPON A SMALL SECTION OF THE
SPECTRUM OF PRESENT-DAY FXED PROSTHODONTICS.
